TEACHING CASE 46

Menopause
Student Handout

Clinical Case:

A 53-year-old, G3P3, whose last menstrual period was 4 months ago presents to the
office with hot flashes, emotional lability, and insomnia. She experiences the hot flashes
2-3 times per day and occasionally at night. She has been having trouble sleeping and is
extremely fatigued. Since age 14, her periods have been regular until 2 years ago, when
they began to space out to every 2-3 months. She is sexually active and recently has
noted some dyspareunia. The patient works as a receptionist and rarely exercises. She
smokes 2 packs of cigarettes a day and drinks alcohol socially. She recently started
taking a soy supplement. She does not have any pertinent gynecological, medical or
surgical history. Her family history is significant for her mother sustaining a hip
fracture at age 60 and a sister with breast cancer and high cholesterol. On examination,

has mildly decreased vaginal rugae and a pale, small cervix. No masses or tenderness
are palpated on bimanual exam.

Discussion Questions:

1. What are the symptoms of menopause?

2. How do you make the diagnosis of menopause?

3.

4. How do you diagnose and treat atrophic vaginitis?

5. How do you counsel a patient regarding estrogen and alternative therapies?

6. What laboratory and diagnostic tests would you order for this patient?

References:

Essentials of Obstetrics and Gynecology by Hacker and Moore, 4th Edition, Chapter 34.
Obstetrics and Gynecology by Beckmann, et al, 5th Edition, Chapter 38.
 Menopause
Preceptor Handout

Women spend as much as one-third of their lives in the postmenopausal years. It is

important for physicians to understand the physical and emotional changes caused by
estrogen depletion.

The APGO Educational Objectives related to this topic are the following:

A. Describe physiologic changes in the hypothalamic-pituitary-ovarian axis associated

with perimenopause/menopause
B. Perform an assessment of the symptoms and physical findings associated with
hypoestrogenism *
C. Describe appropriate management of menopausal/ perimenopausal symptoms
D. Counsel patients regarding menopausal issues *
E. List long term changes associated with menopause, including osteoporosis

*Designated as Priority One in the APGO Medical Student Educational Objectives, 8 th

Edition
 Menopause
Preceptor Handout

Clinical Case:

A 53-year-old, G3P3, whose last menstrual period was 4 months ago presents to the
office with hot flashes, emotional lability, and insomnia. She experiences the hot flashes
2-3 times per day and occasionally at night. She has been having trouble sleeping and is
extremely fatigued. Since age 14, her periods have been regular until 2 years ago, when
they began to space out to every 2-3 months. She is sexually active and recently has
noted some dyspareunia. The patient works as a receptionist and rarely exercises. She
smokes 2 packs of cigarettes a day and drinks alcohol socially. She recently started
taking a soy supplement. She does not have any pertinent gynecological, medical or
surgical history. Her family history is significant for her mother sustaining a hip
fracture at age 60 and a sister with breast cancer and high cholesterol. On examination,

has mildly decreased vaginal rugae and a pale, small cervix. No masses or tenderness
are palpated on bimanual exam.

Discussion Questions:

1. What are the symptoms of menopause?

Hypoestrogenism is the basis for the common changes of menopause.

Discuss the common signs and symptoms of menopause, such as amenorrhea,
hot flashes, loss of memory, fatigue, altered libido, dyspareunia, urinary
symptoms, breast changes, etc.

2. How do you make the diagnosis of menopause?

Menopause is the permanent cessation of menses and usually occurs between

the ages of 50 and 55, with an average of 50-52 years.
Perimenopausal symptoms usually begin 3 to 5 years before amenorrhea or
postmenopausal levels of hormones.

history of osteoporosis, cigarette smoking, and sedentary lifestyle.

Additional risk factors for discussion include age at menopause or
oophorectomy, white or Asian origin, calcium intake, parity, alcohol and caffeine
intake, and corticosteroid use.
4. How do you diagnose and treat atrophic vaginitis?

Patient usually has vulvar irritation and a moderate discharge (clear or yellow,
can be blood-tinged). Associated urinary symptoms may be present.
Examination shows a clear, watery discharge, with vulvar erythema. Excoriation
may be present. A pale vaginal mucosa, with patches of erythema and even
superficial blood vessels are consistent with atrophy.
The pale or yellow discharge has a pH of 5.5 or higher.
Basal cells replace superficial vaginal epithelial cells and can be seen on a saline
wet mount or Pap test.
Treatment is estrogen and takes 4 to 6 weeks for symptomatic relief.
Associated infections should be treated-consider a sulfa cream.
Discuss importance of evaluating any postmenopausal bleeding.

5. How do you counsel a patient regarding estrogen and alternative therapies?

Risks and benefits of therapy should be reviewed (WHI and other studies).
Contraindications should be discussed.
Treatment options for menopausal symptoms and osteoporosis should be
outlined.
Acknowledge frequent use of complementary and alternative treatments.
Lifestyle modifications should be stressed.

6. What laboratory and diagnostic tests would you order for this patient?

and
symptoms, as well as preventive screening. For example, a TSH should be sent
due to her fatigue and a lipid profile due to the family history. A bone density is
indicated as well.
General health maintenance/screening tests should be ordered. These include a
mammogram, bone density, colonoscopy, etc.
Discuss the guidelines for ordering the above tests (i.e. colonoscopy at age 50,
bone density at age 65, etc.)
Consider discussing new Pap test recommendations.

References:

Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 38 Menopause. Pages 374-383.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 36
Climacteric. Pages 422-428.